Provider Demographics
NPI:1912445214
Name:VILLANUEVA, VERNON (PT)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 FOOTHILLS RD
Mailing Address - Street 2:STE N
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-3621
Mailing Address - Country:US
Mailing Address - Phone:575-532-6054
Mailing Address - Fax:
Practice Address - Street 1:720 BROADWAY ST APT 9
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:NM
Practice Address - Zip Code:87942
Practice Address - Country:US
Practice Address - Phone:210-544-4857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4949208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMW231396137Medicare PIN